Periodontitis Totally Explained

Everything about Periodontal Disease totally explained

Periodontitis (perio = around, dont = tooth, -itis = inflammation) refers to a number of inflammatory diseases affecting the tissues that surround and support the teeth. Periodontitis involves progressive loss of the alveolar bone around the teeth and may eventually lead to the loosening and subsequent loss of teeth if left untreated. Periodontitis is caused by a convergence of bacteria that adhere to and grow on the tooth's surfaces, along with an overly aggressive immune system response against these bacteria. Periodontitis is very common and in the USA has a prevalence of 30-50% of the population, but only about 10% have severe forms. A diagnosis of periodontitis is established by inspecting the soft gum tissues around the teeth with a probe and radiographs by visual analysis to determine the amount of bone loss around the teeth. Specialists in the treatment of periodontal diseases are known as periodontists and in the USA periodontics is an American Dental Association-recognized specialty.
Although the different forms of periodontitis are all caused by bacterial infections, a variety of factors affect the severity of the disease. Important "risk factors" include smoking, poorly controlled diabetes, and inherited (genetic) susceptibility.

Etiology

Periodontitis is an inflammation of the periodontium - the tissues that support the teeth in the mouth. The periodontium consists of four tissues:

the gingiva, or gum tissue
the cementum, or outer layer of the roots of teeth
the alveolar bone, or the bony sockets into which the teeth are anchored
the periodontal ligaments (PDLs), which are the connective tissue fibers that run between the cementum and the alveolar bone.

If left untreated, periodontitis causes progressive, irreversible bone loss around teeth, looseness of the teeth and eventual tooth loss. Periodontitis is a very common disease affecting approximately 50% of U.S. adults over the age of 30 years. Periodontitis is thought to occur in people who have preexisting gingivitis - an inflammation that's limited to the soft tissues surrounding the tooth and doesn't yet affect the alveolar bone.
The primary etiology, or cause, of gingivitis is the accumulation of a bacterial matrix at the gum line, called dental plaque. In some people, gingivitis progresses to periodontitis - with thedestruction of the gingival fibers, the gum tissues separate from the tooth and deepened sulcus, called a periodontal pocket. Subgingival bacteria (those that exist under the gum line) colonize the periodontal pockets and cause further inflammation in the gum tissues and progressive bone loss. Examples of secondary etiology would be those things that, by definition, cause plaque accumulation, such as restoration overhangs and root proximity. If left undisturbed, bacterial plaque calcifies to form calculus, which is commonly called tartar. Calculus above and below the gum line must be removed completely by the dental hygienist or dentist to treat gingivitis and periodontitis. Although the primary cause of both gingivitis and periodontitis is the bacterial plaque that adheres to the tooth surface, there are many other modifying factors. A very strong risk factor is one's genetic susceptibility. Several conditions and diseases, including Down syndrome, diabetes, and other diseases that affect one's resistance to infection also increase susceptibility to periodontitis.
Another factor that makes periodontitis a difficult disease to study is that human host response can also affect the alveolar bone resorption. Host response to the bacterial insult is mainly determined by genetics, however immune development may play some role in susceptibility.

Signs and symptoms

Symptoms may include the following:

occasional redness or bleeding of gums while brushing teeth, using dental floss or biting into hard food (for example apples) (though this may occur even in gingivitis, where there's no attachment loss)

occasional gum swellings that recurs

halitosis, or bad breath, and a persistent metallic taste in the mouth

gingival recession, resulting in apparent lengthening of teeth. (This may also be caused by heavy handed brushing or with a stiff tooth brush.)

deep pockets between the teeth and the gums (pockets are sites where the attachment has been gradually destroyed by collagen-destroying enzymes, known as collagenases)

loose teeth, in the later stages (though this may occur for other reasons as well) Patients should realize that the gingival inflammation and bone destruction are largely painless. Hence, people may wrongly assume that painless bleeding after teeth cleaning is insignificant, although this may be a symptom of progressing periodontitis in that patient.

Prevention

Daily oral hygiene measures to prevent periodontal disease include:

brushing properly on a regular basis (at least twice daily), with the patient attempting to direct the toothbrush bristles underneath the gum-line, so as to help disrupt the bacterial growth and formation of subgingival plaque and calculus.

flossing daily and using interdental brushes (if there's a sufficiently large space between teeth), as well as cleaning behind the last tooth in each quarter.

using an antiseptic mouthwash. Chlorhexidine gluconate based mouthwash or hydrogen peroxide in combination with careful oral hygiene may cure gingivitis, although they can't reverse any attachment loss due to periodontitis. (Alcohol based mouthwashes may aggravate the condition).

regular dental check-ups and professional teeth cleaning as required. Dental check-ups serve to monitor the person's oral hygiene methods and levels of attachment around teeth, identify any early signs of periodontitis, and monitor response to treatment. Typically dental hygienists (or dentists) use special instruments to clean (debride) teeth below the gumline and disrupt any plaque growing below the gumline. This is a standard treatment to prevent any further progress of established periodontitis. Studies show that after such a professional cleaning (periodontal debridement), bacteria and plaque tend to grow back to pre-cleaning levels after about 3-4 months. Hence, in theory, cleanings every 3-4 months might be expected to also prevent the initial onset of periodontitis. However, analysis of published research has reported little evidence either to support this or the intervals at which this should occur. Instead it's advocated that the interval between dental check-ups should be determined specifically for each patient between every 3 to 24 months.
Nonetheless, the continued stabilization of a patient's periodontal state depends largely, if not primarily, on the patient's oral hygiene at home if not on the go too. Without daily oral hygiene, periodontal disease won't be overcome, especially if the patient has a history of extensive periodontal disease.

Treatment of established disease

The cornerstone of successful periodontal treatment starts with establishing excellent oral hygiene. This includes twice daily brushing with daily flossing, mouthwash use. Also the use of an interdental brush (called a Proxi-brush) is helpful if space between the teeth allows. Persons with dexterity problems such as arthritis may find oral hygiene to be difficult and may require more frequent professional care. Persons with periodontitis must realize that it's a chronic inflammatory disease and a lifelong regimen of excellent hygiene and professional maintenance care with a dentist or periodontist is required to maintain affected teeth. Initial Therapy: Removal of bacterial plaque and calculus is necessary to establish periodontal health. The first step in the treatment of periodontitis involves non-surgical cleaning below the gumline with a procedure called Scaling and Root planing. This procedure involves use of specialized curettes to mechanically remove plaque and calculus from below the gumline, and may require multiple visits and local anesthesia to adequately complete. In addition to initial scaling and root planing, it may also be necessary to adjust the occlusion (bite) to prevent excessive force on teeth with reduced bone support. Also it may be necessary to complete any other dental needs such as replacement of rough, plaque retentive restorations, closure of open contacts between teeth, and any other requirements diagnosed at the initial evaluation. Reevaluation: Multiple clinical studies have shown that non-surgical scaling and root planing is rarely successful in periodontal pocket depths greater than 4-5mm (See articles by Stambaugh RV, Int J Periodontics Rest Dent, 1981 or Waerhaug J, J Periodontol, 1978). Therefore it's necessary for the dentist or periodontist to perform a reevaluation 4-6 weeks after the initial scaling and root planing, to determine if the treatment was successful in reducing pocket depths and eliminating inflammation. It has been found that pocket depths which remain after initial therapy of greater than 5-6mm with bleeding upon probing are indicative of continued active disease and will very likely show further bone loss over time. This is especially true in molar tooth sites where furcations (areas between the roots) have been exposed. Surgery: If the initial non-surgical treatment wasn't successful in controlling periodontitis, or if anatomical bony defects persist, periodontal surgery may be necessary to control periodontal disease. There are a myriad of procedures which may be applied, depending on each tooth's site-specific disease pattern. These procedures are usually performed by a periodontist. These procedures include (but are not limited to):

Open flap debridement

Modified Widman flap surgery

Apically positioned flaps with or without osseous resection

Guided tissue regeneration with or without bone grafting Maintenance: Once successful periodontal treatment has been completed, with or without surgery, a lifelong regimen of "periodontal maintenance" is required. This involves regular checkups and cleanings of every 3-4 months to prevent repopulation of periodontitis-causing bacteria, and to closely monitor affected teeth so that early treatment can be rendered if disease recurs.

Assessment and prognosis

Dentists and dental hygienists "measure" periodontal disease using a device called a periodontal probe. This is a thin "measuring stick" that's gently placed into the space between the gums and the teeth, and slipped below the gum-line. If the probe can slip more than 3 millimetres length below the gum-line, the patient is said to have a "gingival pocket" around that tooth. This is somewhat of a misnomer, as any depth is in essence a pocket, which in turn is defined by its depth, for example, a 2 mm pocket or a 6 mm pocket. However, it's generally accepted that pockets are self-cleansable (at home, by the patient, with a toothbrush) if they're 3 mm or less in depth. This is important because if there's a pocket which is deeper than 3 mm around the tooth, at-home care won't be sufficient to cleanse the pocket, and professional care should be sought. When the pocket depths reach 5, 6 and 7 mm in depth, even the hand instruments and cavitrons used by the dental professionals can't reach deeply enough into the pocket to clean out the bacterial plaque that cause gingival inflammation. In such a situation the pocket or the gums around that tooth will always have inflammation which will likely result in bone loss around that tooth. The only way to stop the inflammation would be for the patient to undergo some form of gingival surgery to access the depths of the pockets and perhaps even change the pocket depths so that they become 3 or less mm in depth and can once again be properly cleaned by the patient at home with his or her toothbrush.
If a patient has 5 mm or deeper pockets around their teeth, then they'd risk eventual tooth loss over the years. If this periodontal condition isn't identified and the patient remains unaware of the progressive nature of the disease then, years later, they may be surprised that some teeth will gradually become loose and may need to be extracted, sometimes due to a severe infection or even pain.
According to the Sri Lankan Tea Labourer study, in the absence of any oral hygiene activity, approximately 10% will suffer from severe periodontal disease with rapid loss of attachment (>2 mm/year). 80% will suffer from moderate loss (1-2 mm/year) and the remaining 10% won't suffer any loss.

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